Authors' objectives:

The aim of this review is to evaluate the usefulness of multislice computed tomography for screening and diagnosis of coronary disease.

Authors' results and conclusions: For this report 10 narrative revisions, 9 case series and 4 clinical practice guidelines, one health technology assessment and 5 coverage policies of north-American groups were used. No controlled randomized clinical trials were identified. With respect to assessment of presence of coronary calcium, there is not enough evidence to date to suggest that asymptomatic subjects would experience a clinical benefit after undergoing screening of coronary plaques using MSCT. Most consensuses consider electron beam computed tomography (EBCT), spiral computed tomography (SCT) and MSCT still at their investigational stage for the following:a) detection of coronary artery calcifications as a screening method for asymptomatic subjects with coronary disease; b) detection of coronary artery calcifications in symptomatic patients and c) assessment of coronary graft viability according to calcium presence. MSCT has been indicated as an alternative method to invasive angiography. The literature, for most of the applications proposed, shows low-level evidence. Publications indicate that this method has an overall sensitivity between 79 and 93% to detect coronary obstructions, with a high negative predictive value, 95-98% in the different studies (although this figure can be explained by the effect of including artery segments instead of patients). At present, a problem that this technique poses is the presence of 7-10% of vessels/segments that can not be properly evaluated. With respect to the accuracy of this method compared with coronary angiography to assess graft or endoprosthesis patency, evidence is also insufficient and the few case series show sensitivity and specificity values over 90%, although a lower sensitivity has been described to assess endoprosthesis patency. The main flaw found in the literature lies in that most studies used for their analysis individual coronary arteries or segments, whereas only few papers reported the diagnostic usefulness, taking the patient as analysis unit, which becomes clinically relevant when it comes to decision making. On the other hand, fast heart rate or irregular heart rhythm complicate assessment, and patients who present these characteristics must be excluded or receive medication. Coverage policies: The study is not covered for coronary disease screening. U.S. Medicaid suggests the test could be covered in the following cases a) clarification of prior non-conclusive results or instead of a perfusion test, replacing invasive studies b) as a complementary method to help decision making for the management of symptomatic patients with known cardiac disease, specially to decide if it is necessary to repeat a more invasive study; or c) pre-surgical assessment of congenital anomalies in coronary arteries or great vessels. Other U.S. health agencies and prepaid systems do not give opinion about coverage or do not cover the test.

Authors' recommendations: Most consensus consider EBCT, SCT and MSCT still at their investigational stage for the following: a) detection of coronary artery calcifications as a screening method for asymptomatic subjects with coronary disease; b) detection of coronary artery calcifications in symptomatic patients and c) assessment of coronary graft viability. No study reported that calcification measuring (plaque characterization) reduces the incidence of coronary events or death. As an alternative method to invasive angiography, there is not enough evidence to support that MSCT improves health outcomes in a net fashion, and it has not been demonstrated that this technique is more accurate than conventional angiography to assess coronary arteries. There is also not enough evidence to justify its use as screening method for coronary disease in asymptomatic people. In symptomatic patients, this option could be more cost-effective, but data are still scarce. Only in the U.S, coverage policies were found which consider MSCT use for specific indications.

Authors' methods: Overview

Project Status: Completed

URL for project: http://www.iecs.org.ar/

Year Published: 2005

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Argentina

Organisation Name: Institute for Clinical Effectiveness and Health Policy

Contact Address: Dr. Emilio Ravignani 2024, Buenos Aires - Argentina, C1414 CABA

Contact Name: info@iecs.org.ar

Contact Email: info@iecs.org.ar

Copyright: Institute for Clinical Effectiveness and Health Policy (IECS)